High mortality in patients with tracheoarterial fistulas: clinical experience and treatment recommendations.

Abstract

A tracheoarterial fistula (TAF) is an uncommon but a critical complication of tracheostomy and represents a surgical emergency. Surgical therapy with ligation of the brachiocephalic trunk can be considered as the first choice of treatment to control massive and life-threatening haemorrhage. We describe 3 cases of TAF in patients who had long-term placement of a tracheostomy tube and the occurrence of a severe massive haemorrhage caused by an injured brachiocephalic trunk. All cases required emergent surgical revision. Different surgical techniques were used. In addition to the 3 case reports, we present a review of the literature of published TAF cases, summarize the different measures to control bleeding and compare the operative procedures used in the treatment of TAF. The occurrence of TAF is rare and constitutes a surgical emergency. The mortality rate of tracheoarterial erosion is 100% without surgical intervention for active bleeding into the airway. Therefore, rapid control of bleeding (via digital compression and an overinflated cuff) is the most important and first step of therapy. Subsequent emergency surgery with ligation and resection of the TAF and covering of the trachea should be considered to finally control the massive haemorrhage. In addition, cardiopulmonary bypass and circulatory arrest can be useful for surgical treatment of cases with uncontrollable bleeding. The mortality rate after resection of the fistula remains high. Finally, the most important factors for patient survival and outcomes are quick diagnosis of the TAF and immediate surgical control of bleeding.